Whats going wrong in Recreational Aviation lately?

[Guest pelorus32]

Hi Ian,

 

Yes we can do that when each of us as individuals is trying to determine what went wrong and what we might do.

 

What I am also very interested in is the systemic response to safety and to changing these outcomes. That kind of stuff isn't aided by reading the individual tea leaves.

 

Indeed I'm unconvinced that I as an individual are helped by the current process of accident "investigation" and "reporting", let alone the organisational system and response.

 

regards

 

Mike

 

 

[facthunter]

Pilot Error.

 

The term Pilot Error is so non-specific that it has little meaning., and is generally unhelpfull. I would suggest that it only provides a convenient compartment to allocate BLAME, without contemplating the complexities and any mitigating circumstances that might be relevant. Without any consideration of ALL the factors, will we ever get ahead in the process of understanding the CAUSES?

 

As an example, In the case of the Italian Incident, what if the controls were jammed, prior to the excessive speed event ,or if the pilot had a seizure. I'm not seriously suggesting anything, here or wishing to encourage any speculation ,Just trying to point out that you could be awfully wrong in using this Pilot error concept. What pilot sets out to committ an error. There is always a reason for everything..Nev...

 

 

[John Brandon]

John,I think that is almost spot on John - even one death is unacceptable.

 

The issue that this thread has been digging at is just what does "pilot error" mean?

 

If I fail to get the stick forward during an EFATO and I stall and maybe spin then that's a S&R issue - one form of pilot error.

 

If I persist in conducting aerobatics in an aircraft not designed or approved for that. If those aerobatics are contrary to regulation; then I am a violator. You could maybe fit me in the broad category of pilot error - albeit more active than the stall/spin situation.

 

If I launch in marginal met conditions; persist as the conditions deteriorate; and ultimately if I am a victim of a CFIT; then that's something that I have been told about so often there is apparently no excuse. the fact that these accidents continue suggests that whilst it's pilot error it is probably much more complex and multi-faceted than the other two.

 

I could go on. My real point is that "pilot error" is a very broad territory that doesn't actually help me in arriving at a resolution and resolving the distressing situation of even one death.

 

At one point I am dealing with "simple" S&R failure - probably a skill failure. At other points of the picture I am dealing with quite complex human factors. At yet other points I'm dealing with a willful violation. Each requires a different response.

 

At risk of pre-judging a recent accident, but equally sick of beating about the bush on this: Did the guy in Italy, the guy who specified he was about to conduct a pass in excess of Vne, did he do that in ignorance of the implications of exceeding Vne? Did he do it out of hubris? Did he do it in a false sense of the capabilities of the aircraft? He certainly did it with explicit disregard to the urgings of many people who knew and respected him and were worried about his behaviour. I am aware of no evidence that he had a death wish. Why did he do it? That's a complex question. There are also questions about the flutter performance of the aircraft, the structural integrity of the aircraft etc. A really multifaceted issue. Pilot error? That's too simple to help.

 

I haven't even dealt with maintenance issues or what appears to me to be patterns of equipment failure with particular equipment.

 

Yes even one is too many. No the responses are not simple and simply calling it pilot error doesn't advance our ability to respond.

 

We need multi-faceted responses, I am sure there are no simple solutions.

 

But above all I'm with you John, one is one too many.

 

Kind regards

 

Mike

G'day Mike,

Consider this paragraph from http://www.raa.asn.au/students/airmanship.html ; it demonstrates a relationship between pilot competency, airmanship and pilot error.

 

"Airmanship is the cornerstone of pilot competency. Competency has been defined as the combination of knowledge, skills and attitude required to perform a task well – or to operate an aircraft safely and in all foreseeable situations. A flight operation, even in the most basic low momentum ultralight, is a complex interaction of pilot, machine, practical physics, airspace structures, traffic, weather, planning and risk; and when each and every flight is undertaken it is not only the aircraft which should be airworthy, the total environment – airframe, engine, pilot, atmospheric conditions and flight planning – should allow for the safe, successful conclusion of each operation. It is the perception – founded on the acquired underpinning knowledge – of the state of that total environment and its potential risks that provides the basis for good airmanship and safe, efficient, ERROR free flight. Insufficient perception and insufficient self-discipline create a pilot at risk."

 

However no one is sufficiently competent to undertake any flight that starts to stretch them nor are they as competent in their normal flight environment as they perhaps believe, and every pilot makes errors in flight, most of which are completely inconsequential.

 

All aircraft accidents, from just damaging the wingtip on the hangar door to rolling it up in a fiery ball, are generally the result of a sequence of small errors and/or events and/or judgements each perhaps inconsequential in themselves but when if combined lead to an outcome seemingly grossly out of proportion to the input.

 

Generally we tend to select the most visible decision and classify the accident according to that. Thus if we have an EFATO incident and the pilot decides to turn back and makes it then, if there is any investigation, it will be into the actions/events that caused the engine failure. If the pilot doesn't make it back an investigation verdict will be "pilot error" even though perhaps the pilot only contributed one unwise decision in the sequence of events.

 

The pilot error bucket is very commodious, which is why all aircraft accidents tend to be conveniently tipped into it unless there is enough overweighing evidence to pin it on Air Traffic Control, the aircraft manufacturer, the maintenance personnel or, in desperation, the Bureau of Meteorology. As a consequence the mere classification as 'pilot error' tells you nothing about the root causes of a fatal accident. However you can be pretty sure that then the causes will be found among the perennials — pre-flight preparation and planning, decision making, perception, judgement, fuel management and handling skills.

 

Regarding the recent event in Italy, no one yet knows whether the aircraft exceeded the design diving speed Vd or Vdf [ about 10% greater than Vne and the speed a person with test pilot experience in that type might go to, see http://www.raa.asn.au/groundschool/flutter.html#limiting_airspeeds] and how much g was pulled and what atmospheric turbulence was like, but if speed is thought to be excessive then there will probably be a "pilot error' verdict even though there may be many other contributing factors and persons.

 

At the other extreme you have the criminal actions [i wouldn't downgrade them to "pilot error"] where a pilot decides to do something particularly ill-disciplined [ the beat-up, touching wheels on water, low level aerobatics without the authority of an air display endorsement] where hopefully he [always a male] only kills himself and no-one else.

 

As you noted the pilot errors that are both puzzling and extremely worrying are those where the pilot makes a conscious decision to 'press on' even though he [rarely she] knows it is most unwise to do so. The decision might be associated with deteriorating visibility, a sick engine, lost over inhospitable terrain etc. I am no psychologist so I really have no idea why they do it, perhaps it is just that compunction to go a little bit further or perhaps they believe "it can't happen to me". Who knows?

 

Of course if a design shortcoming, corrosion/aging or maintenance problem is identified as a result of an air safety investigation then the Airworthiness Directive or similar systems come into operation to protect aviators.

 

cheers

 

John

 

 

[Guest pelorus32]

So John,

 

you and I are in furious agreement about the context. The area that I appear to be failing to communicate about is this:

 

We all know that what you and I and so many others have talked about is "right".

 

However to quote you on this subject:

 

"I am no psychologist so I really have no idea why they do it".

 

This is the guts the absolute guts of what I am getting at. Whilst we have no idea really why they do whatever it is (but wait for my footnote on this) we do have access to a set of tried and true strategies for stopping "them" from doing "it".

 

Forgive me if I go to the "big iron" - I can hear the screams of 'not relevant' already. Sorry guys you are wrong. The changes in accident rates that we have seen in the airline arena are driven by dealing with:

 

• systems failures - things in the regulation, organisation, documentation, etc of what we do that contribute holes in the Swiss Cheese;
   
   
  
• CRM - getting aircrew to work with ALL the resources available to them and to use effective methods to work with that information;
   
   
  
• Profiling - understanding who your pilots are and what their strengths and weaknesses are;
   
   
  
• Reporting systems - blame free, confidential and effective;
   
   
  
• Teeth - if you persist in doing bad things then you won't fly any more.
   
   
  
• .....
   
  

 

Suffice to say it isn't about airworthiness most of the time.

 

The airlines know that CRM/HF requires recurrent training in order to keep it in tip-top order.

 

RAAus is using NONE of the significant resources available to it; little of the learning from aviation over the last 20 years about how to train for safety and how to prevent systems failure. We are insular, caring, but not effecting change at the level we need to.

 

What do we know about the people who are our members and the competence that they have to offer? Nothing. Have we inventoried our members about what they have to offer? NO.

 

I know for instance that we have as a member one of the foremost CRM/HF authorities both in Australia and internationally. How are we utilising those skills? Did we know we had this guy out there.

 

This stuff is been there done that for some sectors of aviation. Why do we think that we have to reinvent the wheel?

 

If you sense rising frustration from me then you sense right. This is not me somehow blaming someone. It is me saying that we need to understand that there is nothing new or radical in what we have to do here. But we do need to enlist help from people who have been there and have done this.

 

Footnote: Whilst you and I might not be psychologists John there is a bucketload of good research on why people do these things, a bucketload. It's part of the existing knowledge base that I say we are not effectively tapping into.

 

Footnote 2: Please don't talk to me about freedom and therefore not taking pilot's certificates off them. To quote: freedom's just another word for nothing left to lose. If we don't nail the violators - all of us nail the violators - then someone will take away our freedoms, or more finally someone will die - nothing left to lose. This is not to say that the majority are violators but we all know that some accidents are a result of violation.

 

Footnote 3: Please don't tell me about the proposed GPPP. From where I stand it isn't the solution or any part of it.

 

This is not meant to offend, blame, accuse or anything else. It is meant to be a blunt assessment of our collective failings, of my part of those collective failings. It is meant to be a fearless statement of my views. It is said from a very supportive and caring place. If it makes you twitch then please ask yourself why.

 

Regards

 

Mike

 

 

[Ben Longden]

Mike said;

 

systems failures - things in the regulation, organisation, documentation, etc of what we do that contribute holes in the Swiss Cheese;

 

CRM - getting aircrew to work with ALL the resources available to them and to use effective methods to work with that information;

 

Profiling - understanding who your pilots are and what their strengths and weaknesses are;

 

Reporting systems - blame free, confidential and effective;

 

Teeth - if you persist in doing bad things then you won't fly any more.

 

This could be described as "best practice", and perhaps we all need to remember this and adopt it either formally or informally across the industry.

 

Ben

 

 

[Yenn]

If you know of any pilot who takes risks, what do you do about it? I maintain that one of the best ways to reduce accidents is to talk to the risk takers, point out their stupid ways and also to set a good example.

 

We have all had training and there is a wealth of training material available on the RAAus website, there is also info available on the web about safety.

 

We should also assess our own behaviour to ensure that we stay safe. For example a friend of mine who flies a slower plane is quite happy for me to overtake him on his stbd. side and cut ahead of him at a safe distance with a wing waggle, but doing this the other day I upset his passenger. Won't be doing that again. Happily his passenger admits it was the suddeness of my appearance that was the problem. He got his own back today when he took me up in his Drifter to do some photography. I nearly froze.

 

 

[Guest Rocko]

Here's another thought...

 

Hey all,

 

Some great ideas are coming out of this post. It'll be interesting to see if anything comes of it.

 

Something else did come to me today, after remembering an experience I had a few years ago. I think the RAA aren't the only "authorities" that should be keeping an eye on pilot and aircraft safety.

 

I went to an open day at a club facility, where quite a few aircraft were stored. I'm not commenting on what club. Not my place to do so. At the time, I'd barely started training, so wasn't really in any position to comment on anything at the time. Now, in hindsight, some things did strike me as being unusual, even for a novice.

 

I saw a Jabiru taking off with a passenger, with a wooden prop, into a cloud base of no more than 500 feet, in the rain, for a "quick scenic fly around the area". I asked one of the club officials who was showing me around if this was the normal, and was told the pilot was quite experienced, and pretty much did what he liked. Noone else commented on this whatsoever.

 

I saw plenty of aircraft with "modifications" and "repairs", many of which were excellent. However, some weren't. Some looked extremely dodgy. But they were obviously allowed to keep flying by the club.

 

I also heard a lot of "stories" by members as to how they escaped this particular situation, or that event. Sure, some were unavoidable, but others weren't. The attitude of the fellow club members was more of admiration, than telling them they deserved a good **** kicking.

 

Now, a club is more than just a few fliers storing their planes together, and going on solo flights. It's a group of people who are supposed to be keeping an eye on each other, and watching each others backs. Not covering for the sloppy airmanship or crappy maintenance of a few stupid members. Not only that, but they have the reputation of their club to consider. If some members aren't pulling their weight, and obeying the rules, shouldn't the club be on them like a pound of bricks?

 

Same goes for people allowing others to hangar their aircraft in their hangars. Don't they have some responsibility, too, if they see an aircraft that looks a bit dodgy?

 

But is it being done?

 

It's not "Dobbing" in a fellow pilot, in grounding a pilot or aircraft who could be endangering themselves. It's a club being responsible for all it's members.

 

So, are clubs in fact policing their members activities? Are they performing audits on the airworthiness of the clubs aircraft? If they find problems, are they reporting it to anyone?

 

Anyone have any comments?

 

Scott

 

 

[Yenn]

Where I fly from we don't have a club, we are just a group of pilots who hangar our planes and fly them from the same strip. No club rules, no constitution so we have absolutely no control over others, but we do have a strong feeling for each others safety and critical judgements are passed when necessary, to the offenders face and not behind his back. So far this as kept us all safe and also there is a great sense of cameraderie.

 

If a club is involved there have to be motions passed and speeches made before anything is done and it all has to be in accordance with the constitution. Too slow and unweildly!

 

 

[Guest AVU]

My observations.

 

It is sad that the incidents appear to be on the rise and a lot has been said, and written, about the reasons why incidents happens. A lot of finger pointing seems to cloud the issue. The basic flaw, in a lot that has happened is, that some aviators, are NOT familiar what has been written in their A/C handling book and ignore the warnings in the engine manufacturers handbook. A lot of instructors are teaching the Ab Initio pilot to maintain and service their respective pride and joy L1. If the average aviator neglects to do a proper inspection after their pride and joy comes out of service or effected the services themselves, and the worst happens, then the finger pointing starts. It is also quite handy to have a seperate logbook for the engine to note down little failings in performance, more so, when the time comes for some more serious engine checking.

 

The airframe must also come under the same inspection and be seriously inspected in depth. How many A/C are flying in our sky's that have not been properly inspected.

 

IF YOU ARE NOT SURE PLEASE ASK SOMEONE? Keep our members safe, our sky safe, and tailwind everywhere you fly.

 

Cheers.

 

Steve

 

 

[Guest AVU]

G'day Gang.

 

An observation on my part is that 90% of the accidents and/or incidents can happen due to the fact that (some) pilots seem to live under the impression that they are "bullet" proof and nothing (will or can happen) to them. Take this back to basics. We all learn to fly (for whatever reason) and seek out the nearest or cheapest school from where we live. We gain our certificate and buy an (el cheapo) aircraft to go flying. On the next few flights we undertake, we become more familliar with the "beast" and find that it is not performing as it should. Tinkering and tweaking starts. The systems we use in flying our "beasties" are complex. If you are not familliar with them, please seek advice. You were issued with a L1 to enable you to service your "beasty", mistreat it and it will bite you!!!

 

A lot of fliers are not familliar with the servicing procedures and attempt it on their own bat.

 

Some flying schools are not as experienced in training pilots and should not issue their L1 in the respective class without referring them to someone to enlighten the flier in the maintaining or how to service their ultralights as there are quite a number now floating about the countryside.

 

The life of your "beasty" and yourself hangs into your approach (professional ?) and safeguard the systems that keeps it in the air.

 

More later.

 

Cheers.

 

Steve

 

 

[Guest High Plains Drifter]

After reading through the various complex aurguements in this thread my head is spinning - and I hav'nt had a drink in days.

 

When I purchased my first Ultralight back in the 1980's, there was no licence required and I did what a lot of others did at the time - with no prior aviation experience I tought myself to fly.

 

One thing that was bought to my attention at the time, was that a large number of the Ultralight fatalities were of pilots who had been GA trained.

 

Just some food for thought. HPD